Capital Area Health Network Sliding Fee Scale Eligibility Documentation Form Page 2

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Other Income
Applicant
Spouse
Children
Other
Subtotal
Employer Report Letter – Income Statement
TANF Letter or Food Stamp Notice of Action
Letter
1040 Tax Form with all corresponding W-2 for
most recent calendar year
Statement of Social Security Benefits (SSI,
SSDI, SSRI)
Self Employed Wage Documentation (Schedule
C)
Notarized Child Support Verification Letter
Current Statement of Alimony
Unemployment Benefits
Workers Compensation Benefits
Local cash assistance benefits
Pension of Annuities
Cash amounts received or withdrawn from any
source including savings, investments, trust
accounts, or other resources readily available
Notarized Patient Report Letter – Income
Statement, signed and witnessed by a staff
member
Military Leave and Earnings Statement
Other:
Laboratory Services: Sliding fee scale patients will be charged $15 for lab test(s).
*Pharmacies: Walgreens and Kroger’s are Capital Area Health Network’s preferred pharmacies. For additional information and a
listing of all the pharmacies CAHN has partnered with, please request such information from CAHN’s staff.
By signing this document, I acknowledge that I have read, understand and agree to the terms and conditions of this form. I
understand that I will be bound by these terms and agree that the information supplied on this form is accurate and up-to-date
to the best of my knowledge. I understand that this documentation will expire six (6) months from date of signature. I
understand that I am responsible for contacting Capital Area Health Network if my eligibility status has changed. I understand if
I do not wish to comply with the sliding fee scale policy and disclose my income status at the time of my initial visit, I will be
registered as a full paying patient.
Signature of Patient or Responsible Party:
Date:
Printed Name of Patient or Responsible Party:
Relationship (if not self):
For office use only:
Date Application Completed:
Date Documents Received:
Application and Documents Reviewed by:
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